without someone like me!?!?!?

Keith Humphreys is pretty great in this interview:

Harold Pollack: I should say you’ve also done some research on AA [Alcoholics Anonymous]. I think some folks would be interested to know that, at least according to your research, AA is actually a pretty impressive intervention in some ways.

Keith: Yeah. I don’t mind people who are skeptical of AA, because when I first heard about it, I thought it sounded kind of hokey. I was in a medical school. I met an AA member, and I was like, “What do you do, exactly?” “We sit around in a room. We talk about spirituality and making amends.” I go, “This is run by a psychologist, a psychiatrist?” He goes, “No, no. There’s no one. It’s just alcoholics.” I, already getting socialized a little into the worst parts of professionalism, had a very dismissive response to that. “My god, without someone like me around, how could you possibly cope with anything?” It’s an attitude that is sadly in medicine, but, like I said, fortunately I wasn’t far enough along in my education that I was incapable of further learning. I was taken to open AA meetings, Cocaine Anonymous, and Narcotics Anonymous meetings in Detroit and in Western Michigan, where I was going to school. I thought, “This is pretty interesting.” I could see that my initial snobbery was not well-founded. It was later, when I started doing prospective studies with good measures and had done some work… with actual randomized clinical trials. Lo and behold, it comes out as well or better as do people like me, who have a lot letters after their name. I’m quite comfortable recommending AA to people as something they should try, as well the other…There are other self-help organizations. It’s incredibly easy to get to. It’s motivating. It’s more fun, I think, than [usual medical treatments]…There’s more friendship than you might get from psychotherapy, something like that. We are social creatures. All the evidence we have shows that social ties are good for health. That’s a way to quickly build up some social capital. I think in the long-term, it helps people not just with their drinking but also with things like friendship. Sometimes job-finding happens in AA, finding someone to marry, all that sort of stuff.

Humphrey’s professional humility stands in sharp contrast with this rant at Mark Willenbring’s blog.

Buried in the report, however, is the shocking statistic that a full 56.4% of the programs (publicly- or privately-funded) prescribed no medications whatsoever.

…while publicly-funded treatment programs were almost 14% less likely to prescribe buprenorphine, only 32.5% of all programs offered the medication. Only 20.6% of programs offered disulfiram, 27% offered tablet naltrexone, 27% offered acamprosate, and a slim 13.1% of programs offered injectable naltrexone….

These findings beg the question: why are evidence-based practices so rare and why is this tolerated in addiction treatment but not in other professional treatments? … When patients are not informed of the full array of treatment options, the lack of informed consent becomes an ethical – and likely legal – issue.

First off, why assume that the absence of meds means that evidence-based practices are absent? (There are lots of non-pharmacological evidence-based practices. )

Secondly, Mark Willenbring himself said:

Occasionally I see patients who have been prescribed acamprosate (Campral) for their alcohol dependence. Campral is the med most likely to be prescribed by general psychiatrists because it was marketed to them. In the US, physicians tend to rely on pharmaceutical representatives too much, as opposed to reading the scientific literature themselves. Unfortunately, I don’t think Campral works. Although a few of the first studies showed very strong effects subsequent studies have not. There now have been three large multi-site studies that have shown no effect of acamprosate, including one in Germany. (There had been speculation that acamprosate worked there because people drank more and they had a month of abstinence in the hospital before starting the drug.)

 

Drugs + capitalism + innovation = ?

Andrew Sullivan directs us to a story on “dabs”, a highly concentrated cannabis product:

Most commonly created by a technique in which high quality pot is blasted with butane that is then extracted, these cannabis concentrates approach 70%-to-90% THC. … Brad Gibbs, of Greenest Green, which has just opened a new state-approved lab in Denver Co., filled with $100,000 in equipment, specializing in BHO, says that the new product is so superior, buds will eventually disappear, at least among, “our generation,”—users under 40. “Dabs are the future of cannabis, both recreational and medicinal,” he adds.

The article links to a High Times article expressing concern about the PR impact of this product for the legalization movement:

Assuming we’re able to dismiss the health risks, there is still the public-relations issue: namely, that because the techniques used to make and consume BHO bear an eerie resemblance to those used for harder drugs like meth and crack – and because its potency is so much higher than regular weed – dabbing is ripe for exploitation by the prohibition propaganda machine. At a time when the acceptance of marijuana among the general public is higher than ever, there’s a fear that seeing teenagers wielding blowtorches or blowing themselves up on the evening news might incite a new anti-pot paranoia that could set the legalization movement back decades.

I am reminded of a talk by Bill White on drug trends. He closed by saying something like, “I can’t tell you what the major drugs of abuse of tomorrow will be, but I can tell you that they are already here, and that they will become a problem when someone develops new ways to use them.” To understand his point, consider the impact of the syringe on opiate use and the impact of “rocking” cocaine into crack on that drug’s use. With crack, in particular, it’s worth noting that everyone knew about freebasing for years, but the real innovation in crack was a cheap and easy way to make the freebase experience available to large numbers of users.

Related articles

• Dabs: The World’s Most Powerful and Sought After Weed Product (animalnewyork.com)
• A Dab Will Do Ya (dish.andrewsullivan.com)
• Marijuana Concentrate ‘Clear’ Debuts at Harborside Health Center in Oakland (sfgate.com)
• Black Market Elimination Fail: Draft Pot Rules Call for Ban on Hash and Hash Oil (slog.thestranger.com)

“No” to rehab?

Alcoholism 01 (Photo credit: Wikipedia)

I was asked by a friend to comment on this article.

Here’s the response I sent him:

Well, he’s got a point. But he’s also gotten a lot wrong, including the name of the NIAAA. It’s National Institute on Alcohol Abuse and Alcohol-ism.
What he’s right about is that not everyone who has an alcohol problem needs or should receive treatment. And, surveys of looking at the prevalence and course of alcoholism and addiction find that large numbers of people experience “natural recovery”, “maturing out” or “spontaneous remission”. Some abstain and others moderate.

He interprets these findings as meaning that anyone who chooses to quit, can.

My interpretation of the findings are that “alcohol dependence” does not equal alcoholism and that conflating the two produces a lot of false positives for alcoholism. The NIAAA article says:

In most persons affected, alcohol dependence (commonly known as alcoholism) looks less like Nicolas Cage in Leaving Las Vegas than it does your party-hardy college roommate or that hard-driving colleague in the next cubicle.

Large numbers of college students meet criteria for dependence but will moderate or quit once they graduate, start careers and form families.

We have the same problem in studies of “recovery”: http://wp.me/p1n5A8-2Em

It’s a lot like the stories of Vietnam veteran spontaneous recoveries from heroin addiction: http://wp.me/p1n5A8-1SO

We also know that lots of alcoholics recover without treatment. (Jim and I did.) Whether your an alcoholic or a heavy drinker, you’re more likely to successfully resolve your problem if you have a lot of recovery capital. His 7 things address a lot of recovery capital domains.

I’m a fan of motivational interviewing, we train staff in it (Though I see it as a tool rather than a solution.) and I agree that a confrontive style is both ineffective and unethical. However, studies don’t find it to be more effective than other approaches. Just this week, a study was published that found few differences between MET (based on motivational interviewing) and counseling-as-usual: http://psycnet.apa.org/?&fa=main.doiLanding&doi=10.1037/a0017045

Labeling legal weed

Mark Kleiman’s looking for ideas about how to label marijuana in a hypothetical legal, commercial market:

Imagine – just hypothetically – that a state decided to open a legal (at the state level) commercial market in cannabis, with some of the users intending to use the substance to treat some medical condition and others using it for other purposes.

Such a market would have an advantage over purely illicit markets that the state could require that the product be tested and labeled with its content of active agents. Those labels might (or might not) help consumers what experience to expect from roughly how much of the product, avoiding unintentional overdose. They might also “nudge” users toward less hazardous patterns of use.

We’re pretty sure that THC is the primary “stoning” agent and that CBD (cannabidiol) has some buffering properties against, e.g., panic attacks. It seems likely that lots of the terpenoids that help give the product its flavor and odor also have their own psychoactivity, but the detailed science mostly hasn’t been done. It may also be the case that user-to-user variation in reactions will be higher for cannabis than it is for alcohol.

With respect to edible products, the label might try to inform consumers about how the content of (e.g.) a brownie compares to the content of some more familiar dosage form, such as a joint.

Finally, the label might contain warnings of various kinds: e.g., not to drive under the influence.

Since there’s more relevant information than can be legibly placed on a package label, there could also be required package inserts (as for pharmaceuticals) and/or a state-maintained website with information about cannabis and about how to interpret the information on the label.

There must be some optimal labeling system, but I’m damned if I can figure out what it is.

Some of the comments point out the difficulty of scaling an unprocessed crop, using hot peppers as an example.

 

Related articles

• How to Label Pot (washingtonmonthly.com)
• The sad story of Purple Urkle (samefacts.com)

 

Prescription drug overdose statistics visually

Popular Science has a chart with US overdose deaths by drug:

…the rate of reported overdoses the U.S. more than doubled between 1999 and 2010. About half of those additional deaths are in the pharmaceuticals category, which the CDC has written about before. Nearly three-quarters of the pharmaceuticals deaths are opioid analgesics—prescription painkillers like OxyContin and Vicodin. And while cocaine, heroin and alcohol are all responsible for enough deaths to warrant their own stripes on the chart, many popular illegal drugs—including marijuana and LSD—are such a tiny blip as to be invisible.

A recently published study confirms the relationship between prescription opioid sales and opioid overdoses.

And, SAMHSA reports on the growing role of prescription opioids in treating opioid addiction.

• …the number of clients receiving methadone on the survey reference date increased from about 227,000 in 2003 to over 306,000 in 2011
• The percentage of OTPs offering buprenorphine increased from 11 percent in 2003 to 51 percent in 2011; the percentage of facilities without OTPs offering buprenorphine increased from 5 percent in 2003 to 17 percent in 2011
• The numbers of clients receiving buprenorphine on the survey reference date increased between 2004 and 2011: at OTPs, from 727 clients in 2004 to 7,020 clients in 2011, and at facilities without OTPs, from 1,670 clients in 2004 to 25,656 clients in 2011

Read our position on buprenorphine maintenance here.

Related articles

• Which Drugs Actually Kill Americans (popsci.com)
• Prescription Drug Abuse: Top 10 Things CDC Says You Should Know (pbs.org)
• Agency explains why it’s hard to count deaths from prescription drug overdoses (missoulian.com)

Ten Percent in Recovery – NOT

Here’s the headline at Partnership for a Drug-Free America:

Survey: Ten Percent of American Adults Report Being in Recovery from Substance Abuse or Addiction

Very interesting news, right?

How did they arrive at that number? With a poll that asks, “Did you once have a problem with drugs or alcohol, but no longer do?”

Choose you evidence carefully by rocket ship

Does that measure recovery? I don’t think so.

Recovery has traditionally described achieving abstinence after a severe and persistent substance use problem characterized by loss of control over use. There has been a push to expand the definition to include people who moderate. This question would catch those people. I’m not too concerned about that.

What does concern me is that there are lots (and lots) of people who have a time-limited episode of substance use problems and moderate or stop once they have reason to. Say, a college student who parties too hard his freshman year and moderates or quits once they are confronted with the possibility of flunking out.  Or, how about a pain patient who starts using more than the prescribed dose, running out of prescriptions before the end of the month and doctor shops to get more to avoid withdrawal? He/She finally talk about the problem with their doc and come up with a new pain management plan. Are these people in recovery? I don’t think so. Would they answer yes to the question above? Probably.

I’m all for normalizing recovery, but the message of this article is misleading. The question they used doesn’t really tell me how many people are in “recovery”.

What would legalized pot look like?

A RAND analyst lays out seven important questions regarding the establishment of legal marijuana:

1. Production. Where will legal pot be grown — outdoors on commercial farms, inside in confined growing spaces, or somewhere in between? RAND research has found that legalizing marijuana could make it dramatically cheaper to produce — first because producers will no longer have to operate covertly, and second because suppliers won’t need to be compensated for running the risks of getting arrested or assaulted. After lawmakers decide how it will be grown, production costs will be shaped by the number of producers and other regulations such as product testing.

2. Profit motive. If there is a commercial pot industry, businesses will have strong incentives to create and maintain the heavy users who use most of the pot. To get a sense of what this could look like, look no further than the alcohol and tobacco industries, which have found ingenious ways to hook and reel in heavy users. So will private companies be allowed to enter the pot market, or will states limit it to home producers, non-profit groups or cooperatives? If a state insisted on having a monopoly on pot production, it could rake in a decent amount revenue — but for now, that possibility seems far off in the United States since marijuana remains illegal under federal law.

3. Promotion. Will states try to limit or counter advertisements in the communities and stores that sell marijuana? U.S. jurisprudence against curtailing what’s known as “commercial free speech” could make it tough to regulate the promotion of pot. While a state monopoly system could help control promotion, those advertisements you see for state lotteries should give you pause.

4. Prevention. If pot is legal for adults, how will school and community prevention programs adapt their messages to prevent kids from using? While some proposals to legalize marijuana would divert tax revenues to prevention efforts, the messaging and strategy should probably be in place before legal marijuana ever hits the streets.

5. Potency. Marijuana potency is usually measured by its tetrahydrocannabinol content, or THC — the chemical compound largely responsible for creating the “high” from pot, as well as increasing the risk of panic attacks. Much of the marijuana coming into the U.S. from Mexico is about 6% THC, while the marijuana sold in medical dispensaries in California ranges from 10%-25% THC. Meanwhile, the Dutch are now considering limiting the pot sold at their famed coffee shops to no more than 15% THC.

While THC receives the most of the attention, don’t forget other compounds like cannabidiol, or CBD — which is believed to counter some of the effects of THC.

6. Price. With marijuana, like any other commodity, price will influence consumption and revenues. A growing body of research suggests that when marijuana prices go down, the probability that someone might use marijuana goes up. So retail prices will largely be a function of consumer demand, production costs and tax rates. If taxes are set too high, pot will become expensive enough to create an incentive for an illicit market — exactly what legalization is trying to avoid. The way taxes are set will also have an effect on what’s purchased and consumed — that is, whether pot is taxed by value, total weight, THC content, or other chemical properties.

7. Permanency. The first jurisdictions to legalize pot will probably suffer growing pains and want to make changes later on. They would do well to build some flexibility into their taxation and regulatory regime. For example, while it may make sense to tax marijuana as a function of its THC to CBD ratio, 10 years from now we may have research suggesting a better way to tax. Just in case they change their minds, some pioneering jurisdictions may want to include a sunset provision that would give them an escape clause, a chance — by simply sitting still — to overcome the lobbying muscle of the newly legal industry that will no doubt fight hard to stay in business. As the sunset date approaches, legislators or voters could choose either to keep their legalization regime or to try something different.

 

The Game

Cabinet Magazine has an article on the bizarre history of Synanon from beginning to end:

Soon the number of people wanting to join Dederich’s after-hours sessions grew too big for his living quarters. This was largely due to an influx of drug addicts who had heard of Dederich’s ability to keep people straight. For the addicts, Dederich offered their only chance of salvation. AA didn’t want them and the state offered only hospitalization or prison. Sympathetic to their need, Dederich scraped together some cash and rented an old store on whose front he painted the letters TLC, short for “Tender Loving Care.”

The store was a safe place in which drugs, alcohol, and violence were forbidden. But the reason for going there was Dederich himself. Following the LSD experiment, he had become an awesome presence. He held seminars now in which he would talk for hours on end, weaving psychological and philosophical insights together and ridiculing, cajoling, teasing, and harrying the addicts who surrounded him. And most amazingly, it seemed to be working. When one addict slurred the wordsseminar and symposium together, Dederich suddenly had a name for his project—Synanon. It was a word redolent of “sin,” “Zion,” and, of course, “Alcoholics Anonymous.”

“I knew something,” remembered Dederich, “and I wanted to transmit this to other people. I had the feeling I could really make people more comfortable.” He would choose to do this by making them profoundly uncomfortable. Combining AA’s teachings with the cursory knowledge he had of psychiatry and a heavy dose of Ralph Waldo Emerson’s 1841 essay “Self-Reliance,” Dederich took his natural loquacity and love of rhetorical combat and created a sort of moonshine therapy, a form of treatment that would live on long after Synanon was destroyed and Dederich was disgraced. It was known as the Game.

Check out the rest here.

 

Addiction Inbox

I‘ve been too busy to post very much, but wanted to put out a quick note about Dirk Hanson’s new printed collection of his blog posts from his blog of the same name,  Addiction Inbox.

For some reason, I find that his writing lends itself to the printed format. There’s so much bad information out there on drugs and addiction, but Dirk presents the science in a sound and balanced. Check out his book and his blog.

 

In the doctor’s office

90 day humility by katyhutch

Anna David shares her personal experience with an all-too-common problem. Doctors who don’t understand addiction and do more harm than good:

I continued to see my pinkie-ring psychiatrist for the next year or so, because he told me I had to if he was to keep prescribing me Paxil and Ambien—drugs I was convinced I needed. I thought he was a terrible psychiatrist and a worse person, and found the $250 half-hour sessions a serious financial strain. But he was a professional, and I was desperate and afraid.

Then one day he calmly explained that he couldn’t continue to see me, and I “must know why.” I theorized it had to do with my constantly telling him I’d gone out of town again and—would you believe it—had left my bottle of Ambien in Houston or Vegas (in reality I was barely leaving my apartment and taking roughly 10 times the amount he’d prescribed me). But I was too ashamed to say anything, so I only nodded.

He told me to find a new shrink, and that he wouldn’t give me any more Paxil; then he handed me a prescription for six months’ worth of Ambien. At no point did he mention AA, rehab, or even the words “addict” or “addiction.” I left his office hysterically crying, scrip in hand, feeling like he hoped I would kill myself.

It’s a big enough problem that we decided to add it to our education series.